Andrew Codling
PFD Report
All Responded
Ref: 2017-0339
All 1 response received
· Deadline: 12 Feb 2018
Coroner's Concerns (AI summary)
A community health team's voicemail to a patient missed an opportunity to reinforce crisis support numbers, potentially contributing to a missed chance to prevent self-harm over a weekend.
View full coroner's concerns
Senior Coroner: The Court House Woburn Street: AMPTHILL. Bedfordshire; MK45 2IIX Tei 41300-300-6559 Fax 0300-300-8267 The
_ The last call from the Community Health Team to the deceased's mobile went to voice mail. It reportedly said it is 3.57pm [Friday] now and am leaving the office at 4.0Opm. have literally 3 minutes to call me otherwise call me Monday if you still need something" .
(2) That call was in response to a call by the deceased_ (3) That call missed the opportunity to re-inforce the fact that there were other means of help should the deceased require it, including the crisis numbers already provided by the Service_ Reminding the deceased that there was provision to provide support before Monday morning may have been all the deceased required to avoid taking the decision to hang himself particularly, bearing in mind it was the deceased who had initiated the call ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe East London NHS Foundation Trust have the power to take such action. YOUR RESPONSE You are under a duty to respond to this Report within 56 days of the date of this report, namely by 7th August 2017 . the coroner; may extend the period. Your Response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed COPIES and PUBLICATION have sent copy of my report to the Chief Coroner and to the following Interested Persons: Paula Codling: am also under a duty to send the Chief Coroner a copy of your Response Senior Coroner; The Court House; Woburn Street; AMPTHILL, Bedfordshire, MK4S ZHX Tel 0300-300-6559 Fax 0300-300-8267 You
The Chief Coroner may publish either or both in a complete or redacted or summary form_ He may send copy of this Report to any person who he believes may find it useful or of interest; You may make representations to me_ the coroner at the time of your response, about the release or the publication of your response by the Chief Coroner. Dated 23rd June 2017 IAN PEARS Acting Senior Coroner Bedfordshire & Luton Senior Coroner The Court House, Woburn Street: AMPTHILL, Bedfordshire. MK45 2HX Tel (300-30u-6559 Fax 0300-300-8267
_ The last call from the Community Health Team to the deceased's mobile went to voice mail. It reportedly said it is 3.57pm [Friday] now and am leaving the office at 4.0Opm. have literally 3 minutes to call me otherwise call me Monday if you still need something" .
(2) That call was in response to a call by the deceased_ (3) That call missed the opportunity to re-inforce the fact that there were other means of help should the deceased require it, including the crisis numbers already provided by the Service_ Reminding the deceased that there was provision to provide support before Monday morning may have been all the deceased required to avoid taking the decision to hang himself particularly, bearing in mind it was the deceased who had initiated the call ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe East London NHS Foundation Trust have the power to take such action. YOUR RESPONSE You are under a duty to respond to this Report within 56 days of the date of this report, namely by 7th August 2017 . the coroner; may extend the period. Your Response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed COPIES and PUBLICATION have sent copy of my report to the Chief Coroner and to the following Interested Persons: Paula Codling: am also under a duty to send the Chief Coroner a copy of your Response Senior Coroner; The Court House; Woburn Street; AMPTHILL, Bedfordshire, MK4S ZHX Tel 0300-300-6559 Fax 0300-300-8267 You
The Chief Coroner may publish either or both in a complete or redacted or summary form_ He may send copy of this Report to any person who he believes may find it useful or of interest; You may make representations to me_ the coroner at the time of your response, about the release or the publication of your response by the Chief Coroner. Dated 23rd June 2017 IAN PEARS Acting Senior Coroner Bedfordshire & Luton Senior Coroner The Court House, Woburn Street: AMPTHILL, Bedfordshire. MK45 2HX Tel (300-30u-6559 Fax 0300-300-8267
Responses
Action Taken
East London NHS Trust has developed and implemented a new protocol within CMHTs regarding the use of mobile phones in communication with service users, including an explanatory letter with contact information and guidance for responding to messages. (AI summary)
East London NHS Trust has developed and implemented a new protocol within CMHTs regarding the use of mobile phones in communication with service users, including an explanatory letter with contact information and guidance for responding to messages. (AI summary)
View full response
Dear Sir Inquest touching upon the death of Andrew Codling This is a formal response to your Regulation 28 Report dated 23r8 June in which you set out your concerns relating to the care Mr Codling received from East London` NKS Foundation Trust Your concerns related specifically to the handling of & telephone call made by a member of staff at the Community Mental Health Team (CMHT) to Mr Codling: The call had been in response to a message left by Mr Codling on the mobile phone of the member of staff, The call was returned the same Friday afternoon: As Mr Codling had not answered the call the member of staff left & voicemail message asking Mr Codling to call him back within the next few minutes or the matter would be dealt with on Monday: You were concerned that the member of staff had missed the opportunity to reinforce that there were other means of help shouid Mr Codling require it. In response to the concerns raised a new protocol has been developed and implemented within the CMHTs The protocol provides guidance to staff in relation to the use of mobile phones in communication with service users_ Where a member of staff provides a service user with their mobile phone number an explanatory letter is now provided. This includes information on who can be contacted should the call not be answered, depending on the nature of the call and what assistance is required. Chair: Marie Gabriel Chief Executive: Dr Navina Evans day;
The Protocol also provides clear guidance to staff when responding to messages from service users, in the event the service user does not answer the call, The Protocol requires staff to leave & message providing relevant information on who to call in the event they require urgent support (ie Duty Worker, Crisis Team or ARE) and provide the relevant telephone numbers. This will ensure that in similar circumstances service users will be clear that there are other options available to them should their care coordinator not be available that the action taken provides you with assurance that the Trust has taken appropriate action and that your concern has been adequately addressed_ If you do require further information please do nof hesitate to contact me_
The Protocol also provides clear guidance to staff when responding to messages from service users, in the event the service user does not answer the call, The Protocol requires staff to leave & message providing relevant information on who to call in the event they require urgent support (ie Duty Worker, Crisis Team or ARE) and provide the relevant telephone numbers. This will ensure that in similar circumstances service users will be clear that there are other options available to them should their care coordinator not be available that the action taken provides you with assurance that the Trust has taken appropriate action and that your concern has been adequately addressed_ If you do require further information please do nof hesitate to contact me_
Sent To
- East London NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
12 Feb 2018
All responses received
About PFD responses
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